ABOUT PSEUDOBULBAR AFFECT (PBA)

Actor portrayal of a resident with Pseudobulbar Affect, or PBA, crying symptoms

What is Pseudobulbar Affect (PBA)?

Terminology used to answer "what is PBA?" has varied in the scientific literature, which has contributed to debate and confusion. Commonly used terms include involuntary emotional expression disorder, emotional lability, affective lability, emotional dysregulation, pathological laughter and crying, emotional dysregulation, emotional incontinence, and emotionalism.1,2 The condition is called “pseudobulbar” because it is associated with damage to the corticobulbar tract in the brain.4

To provide your patients with a proper diagnosis, it is important to understand PBA’s definition and recognize the underlying neurologic conditions most commonly associated with PBA.

What is PBA?

Pseudobulbar Affect is a neurologic condition that can occur secondary to other neurologic conditions or brain injuries. PBA is characterized by involuntary, sudden, frequent laughing and/or crying that is exaggerated or incongruent with the underlying mood.3

PBA is often comorbid with mood-related disorders such as depression.4-6

Read more on PBA and Depression

Video play icon over Uncovering PBA video
Uncovering PBA
Listen to Nurse Practitioner Cathy describe how she screens for PBA.
Download a transcript of this video.

PBA symptoms are prevalent in patients with various underlying neurologic conditions

PBA most commonly affects patients who have been diagnosed with stroke, dementia or Alzheimer’s disease, traumatic brain injury (TBI), Parkinson’s disease, amyotrophic lateral sclerosis (ALS), and multiple sclerosis (MS). 3, 7

37%
of patients

In 2011, the prevalence of PBA in the U.S. was approximately 2 million cases among patients with underlying neurologic conditions or brain injury. In a multicenter registry (N=5,290), 37% of patients with any one of six associated neurologic conditions scored a Center for Neurologic Study-Lability Scale (CNS-LS) score of 13 or greater, suggesting the presence of PBA symptoms.3,7,a

Presence of PBA laughing and/or crying symptoms in select neurologic conditions7, a

Neurologic Condition
(n, mean age of patients)
CNS-LS ≥ 13 CNS-LS ≥ 21 Mean years from primary condition diagnosis to study enrollment
Traumatic brain injury
(n=590, 46 yrs)
52% 16% 10.3 (n=347)
Multiple sclerosis
(n=1,215, 49 yrs)
46% 12% 9.9 (n=785)
Amyotrophic lateral sclerosis
(n=125, 60 yrs)
45% 12% 2.3 (n=108)
Stroke
(n=757, 68 yrs)
38% 9% 4.6 (n=395)
Alzheimer's disease
(n=1,799, 79 yrs)
29% 7% 3.7 (n=656)
Parkinson's disease
(n=804, 73 yrs)
26% 6% 5.3 (n=386)

a For more information on the CNS-LS and how it was used, see the PRISM Study Design below.

How many of your patients have symptoms of PBA?

The information below shows how many people in the U.S. may have laughing and/or crying symptoms suggestive of PBA. It’s also important to understand how PBA symptoms can be mischaracterized for symptoms of depression or of an underlying neurologic condition so that you can make an accurate diagnosis.

Neurologic Condition PRISM Study7
CNS-LS ≥ 13
Estimated incidence or prevalence in the United States
Traumatic brain injury
(n=590, 46 yrs)
Up to 52%
(may have symptoms suggestive of PBA)
As many as  2.9 million people in the U.S.  were diagnosed with a TBI in 2014 at emergency department visits, hospitalizations, and death.14
Multiple sclerosis
(n=1,215, 49 yrs)
Up to 46%
(may have symptoms suggestive of PBA)
Nearly 1 million Americans are living with MS.18
Amyotrophic lateral sclerosis
(n=125, 60 yrs)
Up to 45%
(may have symptoms suggestive of PBA)
About 5,000 Americans are diagnosed every year,  with over 30,000 currently living with ALS.16,17
Stroke
(n=757, 68 yrs)
Up to 38%
(may have symptoms suggestive of PBA)
Each year, more than 795,000 people in the U.S. have a stroke, which is a leading cause of long-term disability.10
Alzheimer's disease
(n=1,799, 79 yrs)
Up to 29%
(may have symptoms suggestive of PBA)
More than  6 million people  in the U.S. are believed to have Alzheimer’s disease.12
Parkinson's disease
(n=804, 73 yrs)
Up to 26%
(may have symptoms suggestive of PBA)
Nearly 1 million Americans are living with Parkinson’s disease.15

PBA symptom prevalence in the long-term care setting may differ.20

Read more about PBA in the long-term care setting

PBA is a distinct condition that should be diagnosed and treated separately from these other underlying neurologic conditions or brain injuries.

Once you've made a PBA diagnosis, you can document your decision with ICD-10 code F48.2.19

Understanding PBA

As a healthcare provider, Dr. Fisher shares his experience with PBA patients.

Play video icon over Prevalence of PBA in Your Practice Video
Prevalence of PBA in Your Practice
Hear from Dr. Fisher about the common ways patients with PBA describe their condition.
Download a transcript of this video.
Play video icon over The Importance of Screening for PBA Video
The Importance of Screening for PBA
Dr. Fisher shares why some doctors screen all their patients for PBA.
Download a transcript of this video.
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References: 1. Ahmed A, Simmons Z. Pseudobulbar affect: prevalence and management. Ther Clin Risk Manag. 2013;9(1):483-489. 2. Colamonico J, Formella A, Bradley W. Pseudobulbar affect: burden of illness in the USA. Adv Ther. 2012;29(9):775-798. 3. Work SS, Colamonico JA, Bradley WG, Kaye RE. Pseudobulbar affect: an under-recognized and under-treated neurological disorder. Adv Ther. 2011;28(7):586-601. 4. Miller A, Pratt H, Schiffer RB. Pseudobulbar affect: the spectrum of clinical presentations, etiologies and treatments. Expert Rev Neurother. 2011;11(7):1077-1088. 5. Cummings JL, Arciniegas DB, Brooks BR, et al. Defining and diagnosing involuntary emotional expression disorder. CNS Spectr. 2006;11(S6):1-7. 6. Parvizi J, Arciniegas DB, Bernardini GL, et al. Diagnosis and management of pathological laughter and crying. Mayo Clin Proc. 2006;81(11):1482-1486. 7. Brooks BR, Crumpacker D, Fellus J, Kantor D, Kaye RE. PRISM: a novel research tool to assess the prevalence of pseudobulbar affect symptoms across neurological conditions. PLoS ONE. 2013;8(8):e72232. 8. Moore SR, Gresham LS, Bromberg MB, Kasarkis EJ, Smith RA. A self report measure of affective lability. J Neurol Neurosurg Psychiatry. 1997;63(1):89-93. 9. Smith RA, Berg JE, Pope LE, Callahan JD, Wynn D, Thisted RA. Validation of the CNS emotional lability scale for pseudobulbar affect (pathological laughing and crying) in multiple sclerosis patients. Mult Scler. 2004;10(6):679-685. 10. Centers for Disease Control and Prevention. Stroke Facts. https://www.cdc.gov/stroke/facts.htm. Updated May 25, 2021. Accessed June 22, 2021. 11. Crumpacker DW, Engelman WA. Identifying pseudobulbar affect in Alzheimer’s disease and dementia. US Neurol. 2014;10(1):10-14. 12. Alzheimer’s Association. Facts and figures. https://www.alz.org/alzheimers-dementia/facts-figures. Accessed June 30, 2021. 13. Engelman WA, Hammond FM, Malec JF. Diagnosing pseudobulbar affect in traumatic brain injury. Neuropsychiatr Dis Treat. 2014;10:1903-1910. 14. Centers for Disease Control and Prevention (2021). Surveillance Report of Traumatic Brain Injury-related Hospitalizations and Deaths by Age Group, Sex, and Mechanism of Injury—United States, 2016 and 2017. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. 15. Parkinson’s Foundation. Understanding Parkinson’s: Statistics. https://www.parkinson.org./Understanding-Parkinsons/Statistics. Accessed June 22, 2021. 16. ALS–Amyotrophic Lateral Sclerosis. Johns Hopkins Medicine website. https://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/als/conditions/als_amyotrophic_lateral_sclerosis.html. Accessed June 22, 2021. 17. Centers for Disease Control and Prevention. Prevalence of Amytrophic Lateral Sclerosis—United States, 2015. MMWR. 67(46):1285-1289. 18. National Multiple Sclerosis Society. MS Prevalence FAQs. https://www.nationalmssociety.org/About-the-Society/MS-Prevalence/MS-Prevalence-FAQ. Accessed June 23, 2021. 19. World Health Organization. ICD-10-CM tabular list of diseases and injuries (2021). https://www.cdc.gov/nchs/icd/icd10cm.htm. Published 2021. Accessed June 21, 2021. 20. Foley K, Konetzka T, Bunin A, Yonan C. Prevalence of pseudobulbar affect symptoms and clinical correlates in nursing home residents. Int J Geriatr Psychiatry. 2016;31(7):694-701.

INDICATION AND USAGE

NUEDEXTA® (dextromethorphan HBr and quinidine sulfate) is indicated for the treatment of pseudobulbar affect (PBA). PBA occurs secondary to a variety of otherwise unrelated neurologic conditions, and is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying. PBA episodes typically occur out of proportion or incongruent to the underlying emotional state. PBA is a specific condition, distinct from other types of emotional lability that may occur in patients with neurologic disease or injury.

IMPORTANT SAFETY INFORMATION

CONTRAINDICATIONS

Quinidine and Related Drugs: NUEDEXTA contains quinidine, and should not be used concomitantly with other drugs containing quinidine, quinine, or mefloquine.

Hypersensitivity: NUEDEXTA is contraindicated in patients with a history of NUEDEXTA-, quinine-, mefloquine-, or quinidine-induced thrombocytopenia, hepatitis, bone-marrow depression, lupus-like syndrome, or known hypersensitivity to dextromethorphan (eg, rash, hives).

MAOIs: NUEDEXTA is contraindicated in patients taking monoamine oxidase inhibitors (MAOIs), or in patients who have taken MAOIs within the preceding 14 days, due to the risk of serious and possibly fatal drug interactions, including serotonin syndrome. Allow at least 14 days after stopping NUEDEXTA before starting an MAOI.

Cardiovascular: NUEDEXTA is contraindicated in patients with a prolonged QT interval, congenital long QT syndrome, history suggestive of torsades de pointes, heart failure, patients receiving drugs that both prolong QT interval and are metabolized by CYP2D6 (eg, thioridazine and pimozide), patients with complete atrioventricular (AV) block without implanted pacemaker, or at high risk of complete AV block.

WARNINGS AND PRECAUTIONS

Thrombocytopenia and Other Hypersensitivity Reactions: Quinidine can cause immune-mediated thrombocytopenia that can be severe or fatal. Non-specific symptoms, such as lightheadedness, chills, fever, nausea, and vomiting, can precede or occur with thrombocytopenia. NUEDEXTA should be discontinued immediately if thrombocytopenia occurs.

Hepatotoxicity: Hepatitis, including granulomatous hepatitis, has been reported in patients receiving quinidine, generally during the first few weeks of therapy. Discontinue immediately if this occurs.

Cardiac Effects: NUEDEXTA causes dose-dependent QTc prolongation. QT prolongation can cause torsades de pointes–type ventricular tachycardia, with the risk increasing as the degree of prolongation increases. When initiating NUEDEXTA in patients at risk for QT prolongation and torsades de pointes, electrocardiographic (ECG) evaluation of QT interval should be conducted at baseline and 3 to 4 hours after the first dose. Some risk factors include use with CYP3A4 inhibitors or drugs that prolong QT interval, electrolyte abnormalities, bradycardia, or left ventricular hypertrophy or dysfunction. If patients taking NUEDEXTA experience symptoms that could indicate the occurrence of cardiac arrhythmias (eg, syncope or palpitations), NUEDEXTA should be discontinued, and the patient further evaluated.

Concomitant Use of CYP2D6 Substrates: NUEDEXTA inhibits CYP2D6 and may interact with other drugs metabolized by CYP2D6. Adjust dose of CYP2D6 substrates as needed.

Dizziness: NUEDEXTA may cause dizziness. Take precautions to reduce the risk of falls.

Serotonin Syndrome: Use of NUEDEXTA with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants increases the risk of “serotonin syndrome.”

Anticholinergic Effects of Quinidine: Monitor for worsening in myasthenia gravis.

ADVERSE REACTIONS

The most common adverse reactions (incidence of ≥3% and two-fold greater than placebo) in patients taking NUEDEXTA are diarrhea, dizziness, cough, vomiting, asthenia, peripheral edema, urinary tract infection, influenza, increased gamma-glutamyltransferase, and flatulence.

These are not all the risks for use of NUEDEXTA. Please see Full Prescribing Information.